Modelling the cost-effectiveness of pay-for-performance in primary care in the UK

Abstract

BackgroundIntroduced in 2004, the United Kingdom’s (UK) Quality and Outcomes Framework (QOF) is the world’s largest primary-care pay-for-performance programme. Given some evidence of the benefits and the substantial costs associated with the QOF, it remains unclear whether the programme is cost-effective. Therefore, we assessed the cost-effectiveness of continuing versus stopping the QOF.MethodsWe developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40–74 years (n = 27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994 to 2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of −3.68 per 100,000 population (95% confidence interval –8.16 to 0.80). We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses.ResultsIn the base-case analysis, continuing the QOF increased population-level QALYs and health-care costs yielding an incremental cost-effectiveness ratio (ICER) of £49,362/QALY. The ICER remained >£30,000/QALY in scenarios with and without non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 36% lower (while preserving QOF mortality benefits), and in scenarios where the QOF resulted in substantial reductions in health-care spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 18%, 3% and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively.ConclusionsCompared to stopping the QOF and returning all associated incentive payments to the National Health Service, continuing the QOF is not cost-effective. To improve population health efficiently, the UK should redesign the QOF or pursue alternative interventions.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1126-3) contains supplementary material, which is available to authorized users.

Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

“…The assessment of the cost-effectiveness of P4P, as well as other health policies and health system interventions, is still in its infancy in both settings, with potentially controversial assumptions and methods needing refinement, but remains crucial. 8,36,[40][41][42] The assessment of whether programme benefits are concentrated in certain population groups has been explored more extensively by researchers in HIC [43][44][45] and there are growing numbers of studies examining this issue in LMIC, 28,46 but more evidence could be helpful to address potential equity concerns. 47…”

The effect of ‘paying for performance’ on the management of type 2 diabetes mellitus: a cross-sectional observational study

“…9,27 After 1 year, for example, Kirschner et al found significant improvement for the process indicators for all chronic conditions affected by their PFP. 28 While one study concluded that it would be more cost effective to discontinue PFP in primary care and 'return all incentive payments to the NHS', 29 removal of financial incentives for certain elements of performance indicators covered by the QOF was associated with an immediate decline in performance on quality measures. 30 In the most recent report on the QOF system, NHS England concluded that it had a modest effect on health outcomes and should be continued, but in a way that enables more holistic, person-centred care.…”

Life after QOF

“…The biggest problem has been demonstrating the effectiveness of QOF. Modelling revealed that stopping QOF and leaving the funding within the NHS was more cost effective and that, to improve population health efficiency, QOF needed to be redesigned or replaced with alternative interventions . One study did not show that QOF addressed ethnic disparities in diabetes outcomes despite having the potential to improve inequalities in primary care .…”